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Coroner Investigations and Inquests

Inquest Representation


Whenever there is an unnatural or violent death, an unexplained death or a death in custody or state detention the senior coroner for the area in which the death occurred must hold an investigation into the cause of death. [Section 1 Coroners and Justice Act 2009]

Many coroner’s investigations result in a full inquest hearing at which the corner will hear evidence to help him reach a conclusion on the cause of death, for example accident. In cases of an unexplained death the senior coroner can discontinue the investigation where the post mortem examination establishes the cause of death. If this happens there will be no inquest. Sometimes, the deceased’s family or other interested persons are unhappy when an investigation is discontinued and seek legal advice from Alexander Chambers inquest lawyers. If the Senior Coroner receives a written request from an interested person he must give a written explanation for his reason for discontinuing the investigation. This provides a good starting point to advise on representations to try to persuade the senior coroner to re-open the investigation.

The guideline for getting a case through to a full inquest hearing is 12 months from the date of death. In certain cases, this will not be practical and the inquest will be opened and adjourned pending the outcome of further investigations. The Grenfell Tower deaths are a good example. Because there is a public Inquiry the inquests into the 77 deaths have been suspended and adjourned. The terms of reference for the public inquiry mean that the cause of death is likely to be adequately investigated. Once the public inquiry has concluded the Senior Coroner will only resume the inquests if he concludes there are sufficient reasons for doing so. In cases where the police or other prosecuting authorities (such as the Health and Safety Executive) are conducting an investigation that may result in a person or corporate body being charged with homicide offences the senior coroner has to suspend the investigation pending the outcome. For example, the inquest into the death in August 2016 of a volunteer working on canal repairs remains suspended by the Wiltshire senior coroner pending the conclusion of the investigations by the prosecuting authorities. If no charges are brought the inquest will be resumed. If charges of homicide offences are brought most coroners will wait for the end of the criminal trial before resuming the inquest. But, the inquest can be resumed earlier if the prosecuting authority has no objection.

The statutory purpose of an investigation (which may go through to a full inquest) is set out in Section 3 of the 2009 Act.  It is to answer the questions, who the deceased was, how, when and where the deceased came by his or her death. So, the coroner has a very narrow remit to establish the facts that answer those questions. The jurisdiction is entirely different from a criminal case or civil proceedings such as for clinical negligence. It is fact finding only and the law prevents the coroner from making any determination that is framed in a way that appears to determine criminal liability on the part of a named person, or civil liability. [Section 10 (2) of the 2009 Act.] 

In cases where Article 2 of the Human Rights Act applies the scope of the investigation becomes wider so that the questions how, when and where are expanded to ascertain in what circumstances the deceased came by his death. For example, a death in prison requires an Article 2 investigation. The full inquest will look at the immediate causes of the death as well as the wider background such as whether policies and procedures were followed. A death in hospital does not usually require an Article 2 investigation. In practice the scope of the inquest may be restricted to the immediate days or hours leading up to the death. The inquest lawyers at Alexander Chambers are very experienced in advising interested persons (particularly bereaved families) on the likely scope of the inquest. Where appropriate our lawyers can put forward representations for an Article 2 inquest or for an extended time line in a non- Article 2 inquest. The scope of an inquest is normally decided by the coroner at a Pre-Inquest Review hearing. If any interested person wishes to be represented at the full inquest it is highly desirable to have representation at the Pre-Inquest Review hearing to be able to make arguments about the scope of the inquest and further investigations or evidence the coroner might wish to consider.

After concluding an inquest the coroner has an ancillary power to make a Report to Prevent Future Deaths (PFD) to try and address issues that caused concern and may have contributed to the death or could contribute to a future death if not addressed. A recent example of this was the inquest into the death of Natasha Ednan-Laperouse who died because of an allergic reaction to an ingredient in a Pret a Manger baguette that had not been labelled. The coroner directed a PFD to the Environment Secretary Michael Gove about whether large food business operators should benefit from the current Food Information Regulations. Another PFD was directed to the MHRA and the manufacturers of Epipen about the apparently inadequate length of the needle and the dosage of adrenalin within the device.

If you would like to discuss any aspect of an inquest case in confidence and without obligation, please call Alexander Chambers on 0845 652 0451 and ask to speak to one of our inquest lawyers.

Other Articles:

Representation at inquests
Inquest Conclusions ('Verdicts') and Evidence
Challenging the coroner's decision
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